Perceived Health Status and Capability after Hip Fracture: Secondary Outcomes from an Randomized Controlled Trial.

INTRODUCTION: Hip fractures can have a significant impact on the lives of older people and their families. We conducted a pragmatic randomized controlled trial of post-discharge comprehensive geriatric care (CGC) for community-dwelling older adults after a surgically repaired hip fracture. The objective of this study was to conduct a secondary analysis to compare changes in health status and perceived capability from baseline to 12 months after randomization with: the EuroQol 5-Dimension (EQ-5D-5L) (1) utility score and (2) visual analog scale (VAS); and (3) well-being as measured by participants' perceptions of their ability (or capability) toward completing life activities using the ICEpop Capability Measure for Older People (ICECAP-O). METHODS: We tested the effect of usual care (control) versus usual care and an outpatient CGC clinic (intervention) on mobility after hip fracture in community-dwelling older adults (65 years+). In this secondary analysis, we report the following outcomes: EQ-5D-5L utility score and VAS collected monthly via telephone and ICECAP-O collected in person three times at baseline, 6 months, and 12 months. Data were analyzed using area under the curve and regression adjusted for baseline values for utility scores and capability, and constrained longitudinal data analysis for VAS. RESULTS: We enrolled 53 older adults, including 34 women and 19 men, with mean (SD) age of 80 (8) years. There were no statistical or clinically meaningful differences between groups (control group - intervention group values) for all variables: utility score = -0.028 (95% CI: -0.071, 0.014; p = 0.18); VAS: -0.03 (95% CI: -0.39 to 0.33; p = 0.86); and capability = -0.021 (95% CI: -0.090, 0.046; p = 0.54). CONCLUSIONS: There were no differences in outcomes between groups over 12 months, but values remained constant, contrary to a potential decline for this age group, especially after a major life event like a hip fracture.

Comprehensive Geriatric Care to Improve Mobility after Hip Fracture: An RCT.

BACKGROUND: Comprehensive geriatric care (CGC) for older adults during hospitalization for hip fracture can improve mobility, but it is unclear whether CGC delivered after a return to community living improves mobility compared with usual post-discharge care. OBJECTIVE: To determine if an outpatient clinic-based CGC regime in the first year after hip fracture improved mobility performance at 12 months. METHODS: A two-arm, 1:1 parallel group, pragmatic, single-blind, single-center, randomized controlled trial at 3 hospitals in Vancouver, BC, Canada. Participants were community-dwelling adults, aged ≥65 years, with a hip fracture in the previous 3-12 months, who had no dementia and walked ≥10 m before the fracture occurred. Target enrollment was 130 participants. Clinic-based CGC was delivered by a geriatrician, physiotherapist, and occupational therapist. Primary outcome was the Short Physical Performance Battery (SPPB; 0-12) at 12 months. RESULTS: We randomized 53/313 eligible participants with a mean (SD) age of 79.7 (7.9) years to intervention (n = 26) and usual care (UC, n = 27), and 49/53 (92%) completed the study. Mean 12-month (SD) SPPB scores in the intervention and UC groups were 9.08 (3.03) and 8.24 (2.44). The between-group difference was 0.9 (95% CI -0.3 to 2.0, p = 0.13). Adverse events were similar in the 2 groups. CONCLUSION: The small sample size of less than half our recruitment target precludes definitive conclusions about the effect of our intervention. However, our results are consistent with similar studies on this population and intervention.

Action Seniors! Cost-Effectiveness Analysis of a Secondary Falls Prevention Strategy Among Community-Dwelling Older Fallers.

BACKGROUND: The Otago Exercise Program (OEP) has demonstrated cost-effectiveness for the primary prevention of falls in a general community setting. The cost-effectiveness of exercise as a secondary falls prevention (ie, preventing falls among those who have already fallen) strategy remains unknown. The primary objective was to estimate the cost-effectiveness (incremental cost-effectiveness/utility ratio) of the OEP from a healthcare system perspective. DESIGN: A concurrent 12-month prospective economic evaluation conducted alongside the Action Seniors! randomized critical trial (OEP compared with usual care). SETTING: Vancouver Falls Prevention Clinic (Vancouver, BC, Canada; http://www.fallsclinic.ca). PARTICIPANTS: A total of 344 community-dwelling older adults, aged 70 years and older, who attended a geriatrician-led Falls Prevention Clinic in Vancouver, after sustaining a fall in the previous 12 months. MEASUREMENTS: Main outcome measures included: incidence rate ratio for falls, healthcare costs, incremental cost per fall prevented, and incremental cost per quality-adjusted life year (QALY) gained. RESULTS: The OEP costs $393 CAD per participant to implement. The incremental cost per fall prevented resulted in a savings of $2 CAD. The incremental cost per QALY gained (where QALYs were estimated using the Euro-Qol 5D three-level version [EQ-5D-3L]) indicated the OEP was less effective than usual care. The incremental cost per QALY gained (where QALYs were estimated using the Short Form 6D [SF-6D]) indicated the OEP was more effective and less costly than usual care. The incremental QALYs estimated using the EQ-5D-3L and the SF-6D were not clinically significant and close to zero, indicating no change in quality of life. CONCLUSION: Compared with usual care, healthcare system costs are saved and falls are prevented when older fallers who attend a geriatrician-led falls clinic are allocated to, and provided, the physiotherapist-guided exercise-based falls prevention program (the OEP).

Older Adults' Sedentary Behavior and Physical Activity After Hip Fracture: Results From an Outpatient Rehabilitation Randomized Controlled Trial.

BACKGROUND AND PURPOSE: Prolonged sedentary time and limited physical activity can result in deleterious effects on health and mobility, especially for older adults with fall-related hip fracture. Therefore, the purpose of this study was to examine the effect of a multidisciplinary clinic on sedentary behavior and physical activity (prespecified secondary outcomes) and provide descriptions of activity patterns over 1 year for men and women. METHODS: We conducted a parallel-group, single-blinded randomized controlled trial comparing a multidisciplinary clinic and usual care (intervention) with usual care (control). We recruited 53 community-dwelling older adults aged 65+ years who were 3 to 12 months postfracture and collected data at baseline, 6, and 12 months; study staff were blinded to group allocation. The clinic included a geriatric assessment by the geriatrician, physiotherapist, and occupational therapist. Referrals were made to other professionals, when indicated. We collected the accelerometer-measured sedentary behavior and physical activity at 3 time points. We used linear mixed-effects models to compare groups at 6 and 12 months and mixed models to compare outcomes between men and women. RESULTS: Participants were sedentary for more than 10 hours of a 13-hour day, and there were no significant differences between the study groups at 6 months (2.4 [95% confidence interval: -22.4 to 27.2] minutes) or 12 months (-3.7 [95% confidence interval: -33.6 to 26.1] minutes). Compared with women, men spent 47.2 min/d more in sedentary time (P = .052) and 43.8 min/d less in light physical activity (P = .047). DISCUSSION: Older adults after hip fracture spend prolonged periods of waking hours sedentary with very little activity.

Incontinence and Nocturia in Older Adults After Hip Fracture: Analysis of a Secondary Outcome for a Parallel Group, Randomized Controlled Trial.

Objective: To test the effect of a follow-up clinic on urinary incontinence (UI) and nocturia among older adults with hip fracture. Method: Fifty-three older adults (≥65 years) 3 to 12 months following hip fracture were enrolled and randomized to receive usual care plus the intervention (B4), or usual care (UC) only. The B4 group received management by health professionals, with need-based referrals. UI, nocturia, and quality of life were measured with questionnaires at baseline, 6 months, and 12 months. Results: There were 48 participants included in this analysis, and at baseline, 44% of study participants self-reported UI. At final assessment, six out of 24 B4 participants and 12 out of 24 UC participants reported UI. Four out of five study participants reported nocturia at baseline; this did not decrease during the study. Discussion: Following hip fracture, many older adults report UI and most report nocturia. Health professionals should be aware of the high occurrence of urinary symptoms among older adults post hip fracture.

Reflections on Hip Fracture Recovery From Older Adults Enrolled in a Clinical Trial.

This study describes patients' perspectives on recovery during participation in a randomized controlled trial that tested a postoperative hip fracture management program (B4 Clinic), compared with usual care, on mobility. Semistructured qualitative interviews were conducted with 50 older adults with hip fracture (from both groups) twice over 12 months. A total of 32 women (64%) and 18 men (36%) participated in the study with a mean age at baseline of 82 (range = 65-98) years. A total of 40 participants reported recovery goals at some point during their recovery from hip fracture but only 18 participants realized their goals within 12 months. Recovering mobility, returning to prefracture activities, and obtaining stable health were the most commonly reported goals. Participants described good social support, access to physiotherapy, and positive perspective as most important to recovery. These factors were influenced by participants' knowledge, resources, and monthly contact with study staff (perceived as a form of social support). The most frequently reported barriers to participants' recovery were the onset of complications, pain, and limited access to physiotherapy. Potential implications of these findings include design and modification of new or preexisting fracture programs, prioritizing patient engagement and enhanced knowledge for future clinical research in hip fracture recovery.

Equivalent Fall Risk in Elderly Patients on Hemodialysis and Peritoneal Dialysis.

UNLABELLED: ♦ BACKGROUND: Accidental falls are common in the hemodialysis (HD) population. The high fall rate has been attributed to a combination of aging, kidney disease-related morbidity, and HD treatment-related hazards. We hypothesized that patients maintained on peritoneal dialysis (PD) would have fewer falls than those on chronic HD. The objective of this study was to compare the falls risk between cohorts of elderly patients maintained on HD and PD, using prospective data from a large academic dialysis facility. ♦ METHODS: Patients aged 65 years or over on chronic in-hospital HD and PD at the University Health Network were recruited. Patients were followed biweekly, and falls occurring within the first year recorded. Fall risk between the 2 groups was compared using both crude and adjusted Poisson lognormal random effects modeling. ♦ RESULTS: Out of 258 potential patients, 236 were recruited, assessed at baseline, and followed biweekly for falls. Of 74 PD patients, 40 (54%) experienced 86 falls while 76 out of 162 (47%) HD patients experienced a total of 305 falls (crude fall rate 1.25 vs 1.60 respectively, odds ratio [OR] falls in PD patients 0.78, 95% confidence interval [CI] 0.61 - 0.92, p = 0.04). After adjustment for differences in comorbidity, number of medications, and other demographic differences, PD patients were no less likely to experience accidental falls than HD patients (OR 1.63, 95% CI 0.88 - 3.04, p = 0.1). ♦ CONCLUSIONS: We conclude that accidental falls are equally common in the PD population and the HD population. These data argue against post-HD hypotension as the sole contributor to the high fall risk in the dialysis population.

Functional Disability in Older Adults Maintained on Peritoneal Dialysis Therapy.

UNLABELLED: ♦ BACKGROUND: Older in-center hemodialysis patients have a high burden of functional disability. However, little is known about patients on home chronic peritoneal dialysis (PD). As patients opting for home dialysis are expected to play a greater role in their own dialysis care, we hypothesized that a relatively low number of PD patients would require help with basic self-care tasks (ADL) and instrumental activities of daily living (IADL). ♦ METHODS: We used a cross-sectional study design to measure the proportion of patients aged 65 years and older undergoing outpatient PD who needed help with day-to-day activities. Patients living in nursing homes were excluded from the study. Functional dependence in ADL and IADL tasks were measured by the Barthel and Lawton Scales. Physical performance measures used included the timed up-and-go (TUG) test, chair stands and Folstein mini-mental score (MMSE). ♦ RESULTS: A total of 74 of 76 (97%) eligible PD patients participated. Patients had a mean age of 76.2 ± 7.5 years. Thirty-six percent had impaired MMSE scores, 69% were unable to stand from a chair without the use of their arms and 51% had abnormal TUG scores. Only 8 patients (11%) were fully independent for both ADL and IADL activities. Dependence in one or more ADL activity was reported by 64% of participants, while 89% reported dependence in one or more IADL. ♦ CONCLUSIONS: Impaired physical and functional performance is common in older patients maintained on PD. Collaborative geriatric-renal programs may be beneficial within the dialysis community.

Sedentary Behavior and Physical Activity Patterns in Older Adults After Hip Fracture: A Call to Action.

OBJECTIVES: To characterize patterns of sedentary behavior and physical activity in older adults recovering from hip fracture and to determine characteristics associated with activity. METHODS: Community-dwelling, Canadian adults (65 years+) who sustained hip fracture wore an accelerometer at the waist for seven days and provided information on quality of life, falls self-efficacy, cognitive functioning, and mobility. RESULTS: There were 53 older adults (mean age [SD] 79.5 [7.8] years) enrolled in the study; 49 had valid data and demonstrated high levels of sedentary time (median [p10, p90] 591.3 [482.2, 707.2] minutes/day), low levels of light activity (186.6 [72.6, 293.7]), and MVPA (2 [0.1, 27.6]), as well as few daily steps (2467.7 [617.1, 6820.4]). Regression analyses showed that age, gender, gait speed, and time since fracture were associated with outcomes. CONCLUSIONS: Older adults have long periods of sedentary time with minimal activity. Results are a call to action to encourage people to sit less and move more.

Accidental falls and risk of mortality among older adults on chronic peritoneal dialysis.

BACKGROUND AND OBJECTIVES: More than 40% of elderly hemodialysis patients experience one or more accidental falls within a 1-year period. Such falls are associated with higher mortality. The objectives of this study were to assess whether falls are also common in elderly patients established on peritoneal dialysis and evaluate if patients with falls have a higher risk of mortality than patients who do not experience a fall. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Using a prospective cohort study design, patients ages ≥ 65 years on chronic peritoneal dialysis from April 2002 to April 2003 at the University Health Network were recruited. Patients were followed biweekly, and falls occurring within the first 15 months were recorded. Outcome data were collected until death, study end (July 31, 2012), transplantation, or transfer to another dialysis center. RESULTS: Seventy-four of seventy-six potential patients were recruited, assessed at baseline, and followed biweekly for falls; 40 of 74 (54%) peritoneal dialysis patients experienced 89 falls (adjusted mean fall rate, 1.7 falls per patient-year; 95% confidence interval, 1.0 to 2.7). Patients with falls were more likely to have had previous falls, be more recently initiated onto dialysis, be men, be older, and have higher comorbidity. Twenty-eight patients died during the follow-up period. After adjustment for known risk factors, each successive fall was associated with a 1.62-fold higher mortality (hazard ratio, 1.62; 95% confidence interval, 1.29 to 2.02; P<0.001). CONCLUSIONS: Accidental falls are common in the peritoneal dialysis population and often go unrecognized. Falls were associated with higher mortality risk. Because fall interventions are effective in other populations, screening peritoneal dialysis patients for falls may be a simple measure of clinical importance.

Post-discharge management following hip fracture--get you back to B4: a parallel group, randomized controlled trial study protocol.

BACKGROUND: Fall-related hip fractures result in significant personal and societal consequences; importantly, up to half of older adults with hip fracture never regain their previous level of mobility. Strategies of follow-up care for older adults after fracture have improved investigation for osteoporosis; but managing bone health alone is not enough. Prevention of fractures requires management of both bone health and falls risk factors (including the contributing role of cognition, balance and continence) to improve outcomes. METHODS/DESIGN: This is a parallel group, pragmatic randomized controlled trial to test the effectiveness of a post-fracture clinic compared with usual care on mobility for older adults following their hospitalization for hip fracture. Participants randomized to the intervention will attend a fracture follow-up clinic where a geriatrician and physiotherapist will assess and manage their mobility and other health issues. Depending on needs identified at the clinical assessment, participants may receive individualized and group-based outpatient physiotherapy, and a home exercise program. Our primary objective is to assess the effectiveness of a novel post-discharge fracture management strategy on the mobility of older adults after hip fracture. We will enrol 130 older adults (65 years+) who have sustained a hip fracture in the previous three months, and were admitted to hospital from home and are expected to be discharged home. We will exclude older adults who prior to the fracture were: unable to walk 10 meters; diagnosed with dementia and/or significant comorbidities that would preclude their participation in the clinical service. Eligible participants will be randomly assigned to the Intervention or Usual Care groups by remote allocation. Treatment allocation will be concealed; investigators, measurement team and primary data analysts will be blinded to group allocation. Our primary outcome is mobility, operationalized as the Short Physical Performance Battery at 12 months. Secondary outcomes include frailty, rehospitalizations, falls risk factors, quality of life, as well as physical activity and sedentary behaviour. We will conduct an economic evaluation to determine health related costs in the first year, and a process evaluation to ascertain the acceptance of the program by older adults, as well as clinicians and staff within the clinic. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT01254942.

The intersection of geriatrics and chronic kidney disease: frailty and disability among older adults with kidney disease.

Older adults (aged >or=65 years) comprise the largest segment of the CKD population, and impaired kidney function is linked with unsuccessful aging. Individuals across the spectrum of kidney disease have clinical features of the frailty phenotype, suggesting that frailty is not confined to old age among vulnerable populations. This manifests as a high prevalence of impaired physical performance, emergent geriatric syndromes, disability, and risk of death. Considering the multiple system involvement underlying the symptoms and deficits seen in CKD, especially in the more severe stages, the concept of frailty is a highly useful tool to identify older adults with kidney disease who are on the trajectory of vulnerability leading to decline and death. Further work is needed to characterize the relationship between kidney disease and frailty and to identify opportunities to intervene.

Analysis of recurrent events: a systematic review of randomised controlled trials of interventions to prevent falls.

RATIONALE: there are several well-developed statistical methods for analysing recurrent events. Although there are guidelines for reporting the design and methodology of randomised controlled trials (RCTs), analysis guidelines do not exist to guide the analysis for RCTs with recurrent events. Application of statistical methods that do not account for recurrent events may provide erroneous results when used to test the efficacy of an intervention. It is unknown what proportion of RCTs of falls prevention studies have utilised statistical methods that incorporate recurrent events. METHODS: we conducted a systematic review of RCTs of interventions to prevent falls in community-dwelling older persons. We searched Medline from 1994 to November 2006. We determined the proportion of studies that reported using three statistical methods appropriate for the analysis of recurrent events (negative binomial regression, Andersen-Gill extension of the Cox model and the WLW marginal model). RESULTS: fewer than one-third of 83 papers that reported falls as an outcome utilised any appropriate statistical method (negative binomial regression, Andersen-Gill extension of the Cox model and Cox marginal model) to analyse recurrent events and fewer than 15% utilised graphical methods to represent falls data. CONCLUSION: RCTs that have a recurrent event end-point should include an analysis appropriate for recurrent event data such as negative binomial regression, Andersen-Gill extension of the Cox model and/or the WLW marginal model. We recommend that researchers and clinicians seek consultation with a statistician with expertise in recurrent event methodology.

Otago home-based strength and balance retraining improves executive functioning in older fallers: a randomized controlled trial.

OBJECTIVES: To primarily ascertain the effect of the Otago Exercise Program (OEP) on physiological falls risk, functional mobility, and executive functioning after 6 months in older adults with a recent history of falls and to ascertain the effect of the OEP on falls during a 1-year follow-up period. DESIGN: Randomized controlled trial. SETTING: Dedicated falls clinics. PARTICIPANTS: Seventy-four adults aged 70 and older who presented to a healthcare professional after a fall. INTERVENTION: The OEP, a home-based program that consists of resistance training and balance training exercises. MEASUREMENTS: Physiological falls risk was assessed using the Physiological Profile Assessment. Functional mobility was assessed using the Timed Up and Go Test. Three central executive functions were assessed: set shifting, using the Trail Making Test Part B; updating, using the verbal digits backward test; and response inhibition, using the Stroop Color-Word Test. Falls were prospectively monitored using daily calendars. RESULTS: At 6 months, there was no significant between-group difference in physiological falls risk or functional mobility (P>or= .33). There was a significant between-group difference in response inhibition (P=.05). A falls histogram revealed two outliers. With these cases removed, using negative binomial regression, the unadjusted incidence rate ratio of falls in the OEP group compared with the control group was 0.56. The adjusted incidence rate ratio was 0.47. CONCLUSION: The OEP may reduce falls by improving cognitive performance.

Visual impairment in elderly patients receiving long-term hemodialysis.

BACKGROUND: Visual impairments are associated with low quality of life, impairment of daily activities, and accidental falls. As dialysis patients are increasingly older and more disabled, we sought to assess visual impairments within an elderly dialysis population. Based on data from the general population, we hypothesized that more than 30% of dialysis patients 65 years or older would have visual impairment manifested by loss of visual acuity, depth perception, or contrast sensitivity. STUDY DESIGN: Single-center cross-sectional study. SETTING & PARTICIPANTS: Patients established on hemodialysis therapy, age older than 65 years. OUTCOMES: The proportion of elderly hemodialysis patients with impairments in visual acuity, contrast sensitivity, and depth perception. MEASUREMENTS: Lighthouse Near Visual Acuity Test, Lea Screener contrast sensitivity test (Goodlite, MA, USA), Titmus Stereotest, Folstein Mini-Mental Status Examination. RESULTS: 152 of 159 patients (95.6%) had visual acuity levels less than age-expected values. Under North American (American Medical Association, edition 4) guidelines for disability compensation, 62 patients (39.0%) fulfilled criteria for legal blindness. Sixty patients (37.0%) had poor contrast sensitivity and 48 (30.6%) failed the Housefly component of the Titmus Stereotest. Failing the Housefly component was associated with a lower Folstein Mini-Mental Status Examination score (23.4 +/- 4.2 v 25.1 +/- 3.5; P = 0.01). LIMITATIONS: This study is limited by the cross-sectional study design and abbreviated test protocol used for vision assessment. CONCLUSIONS: Results of this study suggest that elderly hemodialysis patients have a high frequency of visual impairment. Formal low vision assessment and low vision rehabilitation may be useful in elderly dialysis patients. Additional study is required to determine whether the absence of depth perception in this patient group is associated with deteriorating cognitive function.

Geriatric comorbidities, such as falls, confer an independent mortality risk to elderly dialysis patients.

BACKGROUND: As the number of patients aged >/=65 years starting haemodialysis (HD) continues to increase, more patients are at risk of falls, functional decline and cognitive impairment. In an earlier prospective cohort study, we showed that 44% of elderly HD patients had more than one fall within a 1-year period. The objective of this study was to assess whether falls remained predictive of increased mortality risk even after controlling for age, comorbidity, dialysis vintage and laboratory variables. METHODS: Using a prospective, cohort study design, patients aged >/=65 years and on chronic HD during the period April 2002-2003 were recruited. Patients were followed biweekly, and falls occurring within the first year were recorded. Outcome data were collected until death, study end (30 December 2006), transplantation or transfer to another dialysis centre. RESULTS: A total of 162 patients were followed for a median of 32.7 months (quartiles 14-57). In a univariate Cox model with a time-dependent variable for falls status, survival was worse amongst fallers compared to non-fallers (HR 2.13, 95% CI 1.32-3.45; P = 0.002). After adjustment for age, dialysis vintage, comorbidity and laboratory variables, falls were a significant predictor of mortality (HR 1.78, 95% CI 1.07-2.98, P = 0.03). Exclusion of falls associated with concurrent illnesses did not alter the results (HR 1.63, CI 1.02-2.28 P = 0.05). CONCLUSIONS: We conclude that the occurrence of more than one accidental fall in a community-dwelling HD patient aged >/=65 years is associated with an independent increased risk of death. As fall interventions are effective, screening HD patients for falls may be a simple measure of clinical importance.

Utility of the mean cumulative function in the analysis of fall events.

BACKGROUND: Falls are the most common cause of injury among elderly people; half of those people fall recurrently. The objective of these simulation studies was to describe the Mean Cumulative Function (MCF) and to evaluate the utility of the MCF in detecting differences between groups experiencing different patterns of event intensities. METHODS: We specified 250 participants per group with a maximum follow-up time of 365 days. A participant could experience 0, 1, 2, 3, or 4 falls. In the baseline experiment, Groups A and B had an average intensity of 60 and 90 days to the first fall event. These event intensities remained constant for events 2-4. Group C represents a short term "strong" initial impact of the intervention modeled for falls 1 and 2, with an average intensity of one fall per 117 days; however, the intervention wanes to "moderate" for falls 3 and 4 with an average intensity of one fall per 90 days. Group D represents a long-term "strong" impact of the intervention modeled by an average intensity of one fall per 117 days for all subsequent events. RESULTS: The MCF was able to detect differences between groups that had varying intensities of subsequent falls. In Group A, all participants experienced at least one fall, whereas Groups B, C, and D had 4, 9, and 15 participants, respectively, who did not experience any falls. The proportion of participants who had 4 falls declined from 84% to 40% in Groups A and D, respectively. When Group A was compared to Group D, the MCF difference detected the prevention of, on average, one fall per person within 175 days. Discussion. A novel instrument for this field of clinical research--the MCF--allows investigators to compare the average number of falls per participant when the intervention reduces the intensity of subsequent falls.

Causes of death in older peritoneal dialysis patients--can we depend on registry reports?

OBJECTIVES: Despite significant improvements in renal management the mortality associated with dialysis care remains high. Many renal registries report mortality statistics on an annual basis. The objectives of this study were (1) to establish the accuracy of the registered cause of death (CoD) against that determined by a panel of physicians; and (2) to test the feasibility of using the HEMO study CoD classification system in patients on peritoneal dialysis (PD). SETTING: Single centre tertiary-care hospital. PATIENTS AND METHODS: Patients were selected from those aged > or = 65 years who died while receiving PD. The CoD was identified from that registered with the local renal registry, and from clinical records. MAIN OUTCOME MEASURES: (1) Sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV) and kappa score comparing registered and extracted CoD. (2) The proportions of deaths in seven categories using two classification systems. RESULTS: A total of 51 patient charts were reviewed. The agreement between the registered and extracted CoD was poor for all causes of death except malignancy. Kappa scores ranged from 0.55 to 1.0 for different causes. PPV were poor for all except malignancy. Comparison of the CoD was highly dependent on the classification method used (e.g., death secondary to infection was 4% and 25% for CORR and HEMO, respectively). CONCLUSIONS: The registered CoD for patients who die while on PD is often inaccurate. Different policies for classifying deaths can have a significant effect on the final reports, which show the proportion of deaths attributed to different diseases. Standardization across registries is required.

Falls and fall-related injuries in older dialysis patients.

Dialysis patients are increasingly older and more disabled. In community-dwelling seniors without kidney disease, falls commonly predict hospitalization, the onset of frailty, and the need for institutional care. Effective fall prevention strategies are available. On the basis of retrospective data, it was hypothesized that the fall rates of older (> or =65 yr) chronic outpatient hemodialysis (HD) patients would be higher than published rates for community-dwelling seniors (0.6 to 0.8 falls/patient-year). It also was hypothesized that risk factors for falls in dialysis outpatients would include polypharmacy, dialysis-related hypotension, cognitive impairment, and decreased functional status. Using a prospective cohort study design, HD patients who were > or =65 yr of age at a large academic dialysis unit were recruited. All study participants underwent baseline screening for fall risk factors. Patients were followed prospectively for a minimum of 1 yr. Falls were identified through biweekly patient interviews in the HD unit. A total of 162 patients (mean age 74.7 yr) were recruited; 57% were male. A total of 305 falls occurred in 76 (47%) patients over 190.5 person-years of follow-up (fall-incidence 1.60 falls/person-year). Injuries occurred in 19% of falls; 41 patients had multiple falls. Associated risk factors included age, comorbidity, mean predialysis systolic BP, and a history of falls. In the HD population, the fall risk is higher than in the general community, and fall-related morbidity is high. Better identification of HD patients who are at risk for falls and targeted fall intervention strategies are required.